=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568075786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D & J DENTAL HOLDINGS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2020
-----------------------------------------------------
Last Update Date | 08/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2249 WEALTHY ST SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-3055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-454-8228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2249 WEALTHY ST SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-3055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-454-8228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. JOHN ALFRED OSTROWSKI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 616-292-7733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------